Choice of route of drug administration in palliative care

Burridge, 2015

Consider the most appropriate and least burdensome route of administration when prescribing drugs for patients with palliative care needs.

The oral route of administration is preferred. It may be necessary to alter the oral method (eg crushing tablets, if appropriate) or consider changing the route of administration when the patient:

• has swallowing difficulties
• is not absorbing drugs given via the oral route
• is vomiting
• requires rapid control of symptoms
• has poor adherence to oral therapy.

Before changing the route of administration, review the patient’s medication regimen to ensure that unnecessary medications are stopped (see Medication rationalisation in palliative care).

There are various reasons for a patient not being able to swallow successfully and this needs to be investigated and managed if appropriate and possible; see Swallowing difficulties and oesophagitis in palliative care. For patients who cannot swallow a tablet or capsule, alternatives for assisting oral administration include:

• using a liquid or dispersible drug preparation
• mixing the powder of a crushed oral tablet or contents of a capsule into soft food.

It is important to check the preparation is appropriate for crushing or dispersing¹. Altering a formulation may impact the drug’s stability and effectiveness, and increase the risk of toxicity (eg with modified-release formulations). Crushing some preparations may have occupational health and safety implications (eg exposure to cytotoxic drugs).

If a patient already has an enteral tube inserted for feeding (eg nasogastric tube, percutaneous endoscopic gastrostomy), this can generally be used for administration of medications. Before using an enteral tube for drug delivery, consider if:

• the drug can be crushed¹
• the drug adheres to the enteral tubing¹
• the position of the tube (and therefore site of drug delivery) will impair drug absorption
• the drug interacts with enteral feeds, requiring a change in timing of feeds to ensure drug absorption.

Alternatively, consider a different route of administration such as:

• a transdermal preparation, if available
• some oral preparations; these can be given by the sublingual or buccal route
• parenteral administration (eg subcutaneous injection).